Jon Webber

Jon Dimaya
Jon Onigama
Christina Post
NURS362
11/06/2015
Ethical DilemmaA 74-year old female patient was admitted to the medical-surgical floor from the Emergency
Dept. She was brought to the ER by HPD for AMS- altered mental status. The police were
called to a condominium in Waikiki by the manager with complaints of a woman trespassing and
refusing to leave the property. The woman claimed to have lived there. According to the
manager, she lived there for over 10 years, but was recently evicted because of non-payment of
rent. Per the patient, she supposedly had a trust and someone had been paying her rent, but is
no longer. She is a confirmed client of IHS- the Institute of Human Services homeless shelter.
Upon arriving at the ER, she had labs drawn, a set of vital signs taken and an IV started. Since
then, she refused subsequent labs, vital signs, assessments and pulled out her IV. The patient
refused to change into a hospital gown and has remained in her street clothes. She was
diagnosed with having starvation ketoacidosis, hypothyroidism, metabolic encephalopathy and
has a history of dementia. The patient refuses to eat and only took small sips of water. Her
rationalization for not eating was that she needed to first have a bowel movement- she hadnt
had a BM in 4-5 days. The patient agreed only to walking the hallway and taking a stool
softener. A social worker at the hospital was able to get in touch with a case manager at IHS
and determined that the patient lives in Hawaii alone, and has children that live on the mainland.
The hospital is working to get in touch with her children to provide the patient with a surrogate
and determine her care and placement after discharge. She was seen by a hospital psychiatrist
and deemed to lack the capacity to make reasonable decisions regarding medical treatment and
self-care. Two weeks after admission, she is still hospitalized, refusing all medications,
assessments, lab draws and vital signs. The social worker is still working to get in touch with the
patients family.
Do the doctors discharge her, not knowing where she will go or what will happen to her?
Establishing surrogacy can take weeks to months, keeping the patient in the hospital. What do
we do in this situation?

Provision 1 of the ANA Code of EthicsThe nurse practices with compassion and respect for the inherent dignity, worth, and unique
attributes of every person.
Section 1.4- The Right to Self- Determination
Respect for human dignity requires the recognition of specific patient rights, particularly, the
right of self-determination. Self-determination, also known as autonomy, is the philosophical
basis for informed consent in health care. Patients have the moral and legal right to determine
what will be done with their own person; to be given accurate, complete, and understandable
information in a manner that facilitates an informed judgment; to be assisted with weighing the
benefits, burdens, and available options in their treatment, including the choice of no treatment;
to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or
penalty; and to be given necessary support throughout the decision-making and treatment
process. Such support would include the opportunity to make decisions with family and
significant others and the provision of advice and support from knowledgeable nurses and other
health professionals. Patients should be involved in planning their own health care to the extent
they are able and choose to participate.
Each nurse has an obligation to be knowledgeable about the moral and legal rights of all
patients to self-determination. The nurse preserves, protects, and supports those interests by
assessing the patients comprehension of both the information presented and the implications of
decisions. In situations in which the patient lacks the capacity to make a decision, a designated
surrogate decision maker should be consulted. The role of the surrogate is to make decisions
as the patient would, based upon the patients previously expressed wishes and known values.
In the absence of a designated surrogate decision-maker, decisions should be made in the best
interests of the patient, considering the patients personal values to the extent that they are
known. The nurse supports patient self-determination by participating in discussions with
surrogates, providing guidance and referral to other resources as necessary, and identifying
and addressing problems in the decision-making process. Support of autonomy in the broadest
sense also includes recognition that people of some cultures place less weight on individualism
and choose to defer to family or community values in decision-making. Respect not just for the
specific decision, but also for the patients method of decision-making, is consistent with the
principle of autonomy.
Individuals are interdependent members of the community. The nurse recognizes that there are
situations in which the right to individual self-determination may be outweighed or limited by the

rights, health and welfare of others, particularly in relation to public health considerations.
Nonetheless, limitation of individual rights must always be considered a serious deviation from
the standard of care, justified only when there are no less restrictive means available to
preserve the rights of others and the demands of justice.
Based on the code of ethics mentioned above, we, as nurses and part of the health care
team cannot deny care to a patient regardless of financial status, medical diagnosis, race, etc..
We respect the patients wishes (autonomy), but perform as much care as we can as a
collective according to what the patient agrees to. For this patient in particular, we cannot
discharge her based on the fact that the psychiatrist deemed the patient unable to make
reasonable decisions regarding medical treatment and self-care. Even though the patient
denies all care from the staff, we still offer it and encourage it and provide teaching when
possible during every shift and hourly rounding until a surrogate can step in to make the medical
decisions.
In the case that the patient becomes represented by one of her children, the health care
team plays a role to improve treatment decision making by the surrogate. Playing the role of a
surrogate is a stressful position because decisions should be made in the best interest of the
patient and not of personal interest of the surrogate. Nurses are with their patients for a great
amount of time throughout their admission. It is plausible that nurses could provide the support
that surrogates need to improve treatment decisions. Emotional support, communication
support, decision making support, and anticipatory grief support are what nurses could provide
for surrogates to lessen the stress of their role and promote patient-centered care (White et al.,
2012).
In the case that the patient remains unrepresented, then a clinician can act as their
surrogate (White, Jonsen, & Lo, 2012). To avoid ethical dilemmas, clinicians should play an
adviser role rather than a decider role in the care of unrepresented patients. The ethical
dilemmas that accompany this responsibility arises when the clinician ecompasses the role of
being the sole decision maker for this patient. These include competing obligations (patients
best interests vs. cost-effectiveness), conflicting interests (personal interests vs. patient
interests), lack of procedural fairness (care of their patient vs. care of other patients),, and
potential criticisms of the clinicians practice. When clinicians use their knowledge along with
being an adviser, treatment becomes patient-centered and dilemmas are best avoided.

Optimal health care results from an exchange between patient and provider with open
communication about the patients wants and needs and the providers judgement and advice.
The issue described involves four ethical challenges.
Veracity: Habitual truthfulness.
How much of what information should be involved in patient care? Is the patient autonomous
enough to effectively communicate their needs and wants? Does the patient have a full and
clear understanding of their situation and the options for treatment? Should certain information
be withheld?
Paternalism: The provider is knowledgeable, but not all-knowing.
Does the provider overlook the patients right to autonomy in the name of beneficence? Do we
as healthcare providers believe we can make better decisions than the patient? Are there
financial or business motivations behind a providers decision?
Autonomy: Fully informed consent or refusal.
What/who motivates the decision made by the patient involving their care? Does the patient
have a clear understanding of their situation? Is their refusal or acceptance of care valid during
a state of mental confusion?
Accountability: Doing the right thing when nobody's looking.
What motivated the decision we made involving the patients care? Did we conduct ourselves
professionally and responsibly? Would we make the same decision again, and will we every
time? Did we uphold the highest standards of practice and care?
Patient choice and respect for personhood are deemed just as important as scientific
knowledge and sound health care advice. We care for many patients, follow many trends, and
predict outcomes of our many interventions. At the same time, we have not cared for this current
patient, followed their trends, nor observed their outcomes before initiating contact.
We must seek a balance between:
-being truthful, yet fastidious with information
-being knowledgeable, but not egotistical
-providing or withholding interventions
-being culpable every day
Potential complications of this particular patients underlying medical condition/denying careHypothyroidsm: goiter, weight gain,heart problems, mental health issues (depression),
neuropathy, myxedema (coma), fatigue, temperature intolerance (cold), muscle weakness, dry
skin, thinning hair, etc.

Malnutrition/Starvation ketoacidosis: Nausea/Vomiting, dehydration, weight loss, abdominal

pain, rapid respiration, altered mental status, coma
Metabolic encephalopathy: altered brain function/mental status due to an imbalance of water,
electrolytes, and other chemicals such as glucose (hyper/hypo) and kidney/liver waste products.
Depending on the area of the brain affected, systemic manifestations can occur such as muscle
weakness/numbness, etc.

References
American Nurses Association. (2011). ANA Code of Ethics. Retrieved from Nursing World:
http://www.nursingworld.org/provision-1#four
Cherry, B. & Jacob, S. R., (2014). Contemporary nursing: issues, trends, & management, (6th
ed.). St. Louis: Elsevier.
Rid, A., & Wendler, D. (2010). Can we improve treatment decision-making for incapacitated
patients?. Hastings Center Report, 40(5), 36-45 10p.
White, D. B., Jonsen, A., & Lo, B. (2012). Ethical challenge: when clinicians act as surrogates
for unrepresented patients. American Journal Of Critical Care, 21(3), 202-207 6p.
doi:10.4037/ajcc2012514
White, D. B., Martin Cua, S., Walk, R., Pollice, L., Weissfeld, L., Seoyeon, H., & ... Arnold, R.
M. (2012). Nurse-led intervention to improve surrogate decision making for surrogates
with advanced critical illness. American Journal Of Critical Care, 21(6), 396-409 14p.
doi:10.4037/ajcc2012223